Life Skills Wyoming - Employment Application
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Last Name *
First Name *
Middle Initial
Social Security Number (required upon hire)
Cell Phone
Home Phone
Work Phone
Email *
Mailing Address
Physical Address
Emergency Contact Name
Emergency Contact Phone Number
Were you referred to Life Skills? *
If you were referred to Life Skills, who referred you?
Highest Grade Completed *
Special Training or Education in a Related Field
How many years of work experience do you have? *
Please rate your safety awareness on the job.  *
Unaware
Very Aware
Please rate your ability to follow directions. *
Incapable
Highly Capable
Are you currently CPR/First Aid certified? *
Are you willing to wear a swimsuit and join participant in the pool? *
Have you ever been convicted of a criminal offense in a court of law? *Answering YES to this question does not constitute an automatic bar to employment. *
If you answered YES to the previous question please provide dates, details and penalties for each occurrence. Do not include minor traffic violations.
Do you have a clean Motor Vehicle Report? (Is your driving record free of citations for moving violations and motor vehicle accidents?) *
If you answered NO to the previous question, please provide details about your driving history.
Do you have any medical or emotional conditions that would limit your ability in performance of job duties? *
If you answered YES to the previous question, please explain.
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